Let's Get Rid of the 6-Month Drop-off

At our practice, the clinician educators who are our full-time faculty spend their days doing multiple different things, serving multiple roles, to teach residents, enhance our practice, and help take care of our patients.

Whenever anyone asks about what it means to be a clinician educator, I say as an example that I spend 50% of my time taking care of my own patients, 50% of my time supervising residents in their practices, 50% of my time doing research, 50% doing administrative tasks, and then there are some other things I do that take up the bulk of my time.

Working with our internal medicine housestaff in our busy ambulatory practice, we supervise them while they see patients in the office, each resident taking care of a panel of patients for whom they serve as primary care physicians, providing longitudinal outpatient medical care of acute and chronic conditions throughout their 3-year residency.

During their internship year, they get to know these patients, meeting them for the first time during their first rotations here in our practice, and establishing a relationship with them as their new primary care physician.

Many of these patients have been taken care of for decades by a sequential series of internal medicine residents; in many ways, these patients have added to the training of almost as many young doctors as we faculty have.

During the first 6 months of their training as new interns, our supervision involves the extra level of oversight, wherein we faculty not only hear the case presentations, but we are required under billing compliance rules to physically see every patient seen by the interns in the practice, no matter how simple or complex.

We do this not just because it is the rule, but also because it makes sense, as they increase their competency and we increase our comfort with their skill sets.

After 6 months -- literally to the day -- from when the interns started practicing back in the summer, they are suddenly allowed to be practicing more independently, if we think they're ready. And for simple low-acuity cases, they can see those patients without us physically being in the room.

We have to hear a case presentation on every single one, before the patient leaves the practice, and we need to be available to come and see the patient ourselves should we have questions about the history or physical examination findings, but otherwise, for the most part, with our guidance and supervision from afar, they can handle simple issues like blood pressure checks, diabetes management, and simple infections, that are billed as low-acuity visits without a lot of complex medical decision-making.

A Large Drop-Off

What we've discovered interestingly (and somewhat worrisome), is that on this 6-month date -- December 21st every year -- the frequency in which the attending faculty is actually physically going into the room to observe the patient of the interns drops off precipitously.

While this complies with the letter of the law, to me it seems to violate the spirit of what should be the embodiment of the trainee-teacher relationship.

Whereas for the first 6 months, for each and every visit, the attendings would go into the room and interact with the patient one-to-one, talking to them, examining them, demonstrating for our trainees how we go about examining a shoulder, palpating a liver, testing for sciatica.

Now suddenly we are nowhere to be found.

These face-to-face interactions, this opportunity for direct observation, both by us seeing what they are doing and for them seeing how we do it, adds great value, to the care of the patient and the education of the house officer.

Reviving the Faculty-Trainee Relationship

I think as we build a more patient-centered medical home, we need to revive and recreate the interaction and experiences of the trainee and the faculty to more closely reflect a true apprenticeship experience.

Many of the residents who rotate through our practice say they love the depth of the teaching they often get from our faculty, and that they value the wisdom and experience of us old-timers.

As the resident's inpatient and outpatient experiences have changed through the years, the exposure each resident gets to each faculty member often gets splintered, shortened, and compressed, so that even after 1 or 2 years of training at our practice, both the house officers and the attendings often say they don't have a great idea about the true skills the others have.

Many physicians I know who trained in the generation before me described how incredibly important the senior mentors who taught them in the hospital were to forming the bedrock of their learning to be a physician, to fully take care of patients.

During the days when residents were actually "residents", living in the hospital, they spent hour after hour at the side of seasoned clinicians, and absorbed the skills of observation, talking to patients, taking the time to get to know them.

Even farther back, in the dark days of medicine, a new young physician was essentially indentured to an elderly senior physician, and like many apprenticeships they paid a price for learning at the master's side.

These days there's an endless rush, a push to see more patients, a push to shorten length of stay, to get patients out of the hospital, to get to the next patient sitting impatiently in the waiting room.

Creating a 'Common Room'

We have been trying to overcome these barriers, to create environments where the benefits of the student-teacher bond can form and thrive.

One pilot we have started has been putting multiple teachers in one room, and having all the residents come to them. This creates a collegial environment, and offers more opportunities for one faculty member to step away from the common room and go see a patient with the resident, encouraging the laying on of hands and passing on of more knowledge. Our hope is that the faculty will feel empowered to step out and go to the patient, since their absence will be less likely to worsen a bottleneck if others remain in the common room.

Starting in 2018, we are going to roll out another pilot program in which a small group of residents will stick with a small group of faculty, and we will try to align the practice sessions of the residents with the supervision sessions of the same faculty, in an attempt to re-create this bond, and we hope this will improve the satisfaction of both the trainees and the trainers, as well as lead to improved care for our patients. We want to lower the resident-to-faculty ratio during supervision sessions as well, in hopes of taking even more of the pressure off.

We hope to study outcomes; wait time; and the satisfaction of patients, residents, and faculty.

I don't think we will ever return to the days of one-on-one apprenticeships, and that's probably a good thing, but I think that as our healthcare system has fractured, and the learning system in which we expect our interns and residents to thrive has become more complex and chaotic, I think we've missed out on a lot of opportunities to really teach what we really know.

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